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The nurse is teaching the family of clients with Alzheimer disease about the disease process. The nurse is using a picture of the brain and highlighting which structures?
- A. Neurotransmitters and cell receptors
- B. Neurofibrillary tangles and amyloid plaques
- C. Brain tissue and receptor sites
- D. Blood vessels with valves
Correct Answer: B
Rationale: The nurse is most correct to instruct the families on neurofibrillary tangles and amyloid plaques. These are characteristic in clients with Alzheimer disease. The other options may have some effect related to the disease but are not characteristic.
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The client asks the nurse if there is a diagnostic test that confirms the diagnosis of Alzheimer disease. Which response by the nurse identifies how the diagnosis is confirmed?
- A. Alzheimer disease is confirmed by validating mental decline and ruling out other diseases.
- B. Alzheimer disease is confirmed by the presence of biomarkers found in the blood.
- C. Alzheimer disease is evident on an MRI that highlights tangles in the brain.
- D. Alzheimer disease is diagnosed when acetylcholine is found in spinal fluid.
Correct Answer: A
Rationale: Much research is being done to determine a diagnostic test confirming Alzheimer disease. The nurse is most correct to confirm that Alzheimer disease is currently validated by noting mental decline and ruling out all other disease processes. Upon autopsy, neurofibrillary tangles are noted. There currently is not a test using biomarkers for Alzheimer disease. An MRI is used to exclude other disease processes and is not specific for Alzheimer disease. Acetylcholine may result in cognitive deficits but is not found in the spinal fluid.
A client diagnosed with schizophrenia is constantly repeating what others say. The nurse would document these symptoms as which of the following?
- A. Loose associations
- B. Delusions
- C. Echolalia
- D. Neologism
Correct Answer: C
Rationale: Echolalia is repeating what others say. Loose associations are a sequence of ideas that are slightly connected. Delusions are false beliefs that cannot be changed by logical reasoning. Neologism is the inventing of new words.
Which of the following is the primary reason for monitoring food and fluid intake and toilet patterns of a client with mental disabilities?
- A. Regular checkup
- B. To identify problems
- C. To determine common symptoms
- D. Physician's record
Correct Answer: B
Rationale: The nurse monitors food and fluid intake and toilet patterns because data collection facilitates problem identification, not as part of a regular checkup or for determining common symptoms. The physician may refer to these records whenever required.
The nurse is providing community education regarding Alzheimer disease. Which client scenario is best for the client with progressing Alzheimer symptoms?
- A. Transfer the client to a behavioral health unit.
- B. Place the client in a personal care home.
- C. Place the client in a long-term care dementia unit.
- D. Maintain the client in the home and bring assistance to the care provider.
Correct Answer: D
Rationale: The best client scenario allows the client to remain in the familiar environment of the client's home while maintaining safety. Home health nurses and nurse aides can aid families in managing client care. Transferring clients to the behavioral health unit, to a personal care home, or a dementia unit all take the client from the home setting, which can be confusing.
A family brings a parent to the physician's office to discuss the parent's decline in cognitive status. The family states that the parent is forgetful and needs reminders to be able to live alone. Following assessment, which stage of Alzheimer disease does the nurse anticipate?
- A. Preclinical
- B. Post clinical
- C. Mild cognitive impairment
- D. Alzheimer dementia
Correct Answer: C
Rationale: The nurse is most correct to anticipate that the client will be diagnosed at the mild cognitive impairment stage of Alzheimer disease. At this stage, the client has noticeable memory problems, however, the memory loss is not serious enough to interfere with independent living.